<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006115
Report Date: 03/24/2022
Date Signed: 03/24/2022 10:47:39 AM

Document Has Been Signed on 03/24/2022 10:47 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:T3 ADULT CARE RESIDENTIAL CAREFACILITY NUMBER:
306006115
ADMINISTRATOR:WILLIAMS, GLORIAFACILITY TYPE:
735
ADDRESS:1726 SOUTH LATUS PLACETELEPHONE:
(714) 797-6057
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 4CENSUS: 0DATE:
03/24/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Thien Luu, Licensee/AdministratorTIME COMPLETED:
11:10 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Kevin Saborit-Guasch and Andrea Mendivil made a scheduled visit to the facility in order to conduct a pre-licensing visit required for an initial application. LPAs arrived at facility, were greeted and granted entry by Thien Luu, licensee and administrator after explaining the purpose of the visit.
At approximately 9:35pm, LPAs accompanied by administrator toured the inside and outside of the facility. Facility is a one-story house with four (4) bedrooms assigned to one client each.

CCLD staff started by touring the physical plant. Hallways are clear of clutter and debris; adequate furnishing elements are being provided to the clients. The two (2) shared bathrooms used by clients are free of toxics and non-slip mats and grab bars have been installed. The water temperature is measured to be 106 degrees in the kitchen and 105 degrees in both shared bathrooms. An ample supply of linen is available to residents. Smoke detectors are present in each room and found to be operational as well as a carbon monoxide detector. The exterior of the physical plant is also free of clutter and debris, with the exception of leftover construction material that will have to be stored inside the garage. Gates at the side of the house are self-latching and can be easily opened in case of evacuation.
An ample supply of perishable and non-perishable food is on hand as well as emergency food and water supply. Weekly nutrition plans are displayed in the kitchen. A sufficient supply of PPE is also stored. Cleaning supplies and toxics are kept under lock. Medication assigned to each client will be centrally stored and locked in the hallway alongside staff and resident files. A fireplace screen is in place in front of the fireplace.
Emergency disaster plan has been provided and reviewed with the licensing application. The mitigation plan has been submitted and will be approved shortly by Community Care Licensing (CCL).

LPA verified all domains of the inspection tool and found no deficiency at this time. The prospective licensee already operates another licensed facility, and the Component III has been completed. The facility is ready to be licensed. An exit interview and a copy of the report were provided at the time of the exit.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1